Christine Aguilar

Quality-of-Life Changes and Hearing Impairment: A Randomized Trial

OBJECTIVE To assess whether hearing aids improve the quality of life of elderly persons with hearing loss. SETTING Primary care clinics at a Bureau of Veterans Affairs hospital. PATIENTS One hundred and ninety-four elderly veterans who were identified as being hearing impaired from a screening survey involving 771 consecutive clinic patients. Of the original 194, 188 (97%) completed the trial. INTERVENTION Subjects were randomly assigned to either receive a hearing aid (n = 95) or join a waiting list (n = 99). MAIN ENDPOINTS: A comprehensive battery of disease-specific and generic quality-of-life measures were administered at baseline, 6 weeks, and 4 months. MEASUREMENTS AND MAIN RESULTS Persons assigned to the two groups were similar in age, ethnicity, education, marital status, occupation, and comorbid diseases. At baseline, 82% of subjects reported adverse effects on quality of life due to hearing impairment, and 24% were depressed. At follow-up, a significant change in score improvements for social and emotional function (34.0; 95% CI, 27.3 to 40.8; P less than 0.0001), communication function (24.2; CI, 17.2 to 31.2; P less than 0.0001), cognitive function (0.28; CI, 0.08 to 0.48; P = 0.008), and depression (0.80; CI, 0.09 to 1.51; P = 0.03) was seen in subjects who received hearing aids compared with those assigned to the waiting list. Six drop-outs (three per group), no crossovers, and no significant changes in cointerventions were seen. Average, self-reported, daily aid use in the hearing aid group was 8 hours. CONCLUSION Hearing loss is associated with important adverse effects on the quality of life of elderly persons, effects which are reversible with hearing aids.

A systematic review of newer pharmacotherapies for depression in adults: evidence report summary.

Depressive disorders, including major depression and dysthymia, are serious disabling illnesses. Approximately one in five persons is affected by a mood disorder at some point (1, 2). The attendant economic costs to society and personal burden to patients and families are enormous. In the United States, the estimated costs of treating depression and the costs incurred by lost productivity exceeded

Association Between Hearing Impairment and the Quality of Life of Elderly Individuals

44 billion in 1990 (3). The personal burden of depression includes higher mortality and impairment in multiple areas of functioning. The World Health Organization estimates that major depression is now the fourth most important cause worldwide of loss in disability-adjusted life-years and will be the second most important cause by 2020 (4, 5). In the late 1980s, the U.S. Department of Health and Human Services sponsored the development of standard treatment guidelines for major depression (6, 7). Since publication of the guidelines, widely publicized emphasis on recognizing and treating depression and development of many new pharmacotherapies have contributed to explosive growth in antidepressant prescribing and increasing pharmacy costs for health plans. Newer antidepressants and readily available herbal remedies have led to wider but sometimes confusing choices for clinicians. The purpose of this paper is to help clinicians make informed choices about antidepressants and herbal therapies for the treatment of depression. Because previous reviews have conclusively demonstrated the efficacy of older antidepressants, this paper focuses on 29 newer antidepressants and 3 herbal remedies (6, 8-11). Older antidepressants and psychosocial therapies are considered only when they are compared directly with a newer antidepressant. Our goal was to summarize data on the efficacy of newer antidepressants and herbal treatments compared with placebo, older antidepressants, and each other for a broad spectrum of depressive disorders. 1.0 Methods English-language and non-English-language literature was identified by using the Cochrane Collaboration Depression, Anxiety and Neurosis Groups specialized registry of 8451 clinical trial articles and from references of pertinent meta-analyses and consultation with experts (1, 6-8, 10, 12-54). The specialized registry contained trials addressing depression identified from multiple sources, including electronic databases, such as MEDLINE, EMBASE, PsychLIT, LILACS, Psyndex, SIGLE, CINAHL, Biological Abstracts, and The Cochrane Library; hand searches of 69 psychiatry-related journals; and contacts with 30 pharmaceutical companies. Sources were searched from 1980 to January 1998 to capture literature relevant to newly released antidepressants. The terms depression, depressive disorder, or dysthymic disorder were combined with a list of 32 specific newer antidepressants and herbal treatments to yield 1277 relevant records. The newer antidepressants are selective serotonin reuptake inhibitors (SSRIs); serotonin and noradrenaline reuptake inhibitors; selective norepinephrine reuptake inhibitors; reversible inhibitors of monoamine oxidase; 5-hydroxy-tryptophan (5-HT2) receptor antagonists; 5-HT1a receptor agonists; -aminobutyric acid (GABA) mimetics; dopamine reuptake inhibitors and antagonists; and herbal remedies, such as hypericum (Table 1). Randomized, controlled trials that were at least 6 weeks in duration; compared a newer antidepressant with another antidepressant (newer or older), placebo, or psychosocial intervention; involved participants with depressive disorders; and had a clinical outcome were reviewed. Two or more independent reviewers identified 315 such trials. Table 1. Classification and Dosage Range of Antidepressants Two persons independently abstracted data from each trial. Data were synthesized descriptively, with attention to participant and diagnostic descriptors; study design, including randomization method and blinding; intervention characteristics; and clinical outcomes. When the studies were conceptually homogenous, quantitative analyses were done by using an empirical Bayes random-effects estimator method. Conceptual homogeneity required similar trial design, comparison of similar drug classes, diagnostic homogeneity, and adequate numbers of trials to justify pooling. Statistical heterogeneity was evaluated by using the chi-square test for homogeneity and Galbraith plots to identify outliers. When statistical heterogeneity was identified, outlier studies were reviewed to identify possible reasons for heterogeneity and studies were reanalyzed without the outliers. Primary outcomes were symptomatic response rate, total discontinuation rates (dropouts), and rates of discontinuation because of adverse events. Secondary outcomes were health-related quality-of-life, functional status, and suicide. Response rates were defined as a 50% or greater improvement in symptoms as assessed by a depression symptoms rating scale or a rating of much or very much improved as assessed by a global assessment method. Response rates were computed by using a modified intention-to-treat approach. This approach computes response rates as the number of patients who stay in treatment and get better divided by the total number of randomly assigned patients. The modified intention-to-treat analysis produces an estimate of treatment effect that is conservative because it assumes that all persons who drop out of the study early receive no benefit. A sensitivity analysis was based on an end point method. In this method, the denominator for the risk ratio was the number of participants who completed follow-up or whose last observation was carried forward. Funnel plots with the Beggs rank-order correlation test and the Egger regression approach were used to estimate the possibility of publication bias whenever a quantitative meta-analysis was performed (54). Publication bias is the tendency of published studies to have different results (usually positive findings) from studies rejected from publication or never submitted for review (usually negative findings). More detailed methods and updates through September 1998 are available in the report on which this manuscript is based (55, 56). This study was funded by the Agency for Healthcare Research and Quality, which specified certain aspects of the study, such as a technical advisory panel and the report format. 2.0 Data Synthesis 2.1 Literature on Newer Antidepressants Three hundred fifteen randomized trials evaluated newer pharmacotherapies for depression. Because some trials had multiple treatment arms, the 315 trials yielded 355 pairwise comparisons. More than 90% of the trials focused on major depression (Table 2). Nine studies focused on dysthymia, a chronic mood disorder characterized by depressed mood for at least 2 years accompanied by two or more vegetative or psychological symptoms. Three studies each examined mixed-anxiety depression and subsyndromal depression, a less symptomatic, acute depression that causes less impairment in social or occupational functioning than major depression. Forty-four trials involved participants with heterogeneous groups of depressive disorders. Most studies (n =206) compared newer and older antidepressants. Serotonin reuptake inhibitors have been the most widely tested; 60 comparisons have been made with placebo, 123 with older antidepressants, and 36 with an SSRI or other newer agent. Table 2. Treatment Trials of Newer Antidepressants and Herbal Remedies More than 90% of the included trials were of short duration (6 to 8 weeks). Among trials reporting visit frequency, patients were seen weekly (62%), every other week (23%), monthly (5%), or on a schedule that varied over time. Trial reporting was often incomplete. Fewer than one third of studies described study settings, few studies described the nature and content of clinical interactions between providers and patients, and fewer than 10% described ethnic background or socioeconomic status of the participants. Of studies that described the study setting, 77 were based in mental health specialty practices and 27 were exclusively in primary care settings. Most studies reported whether recruitment involved inpatient or outpatient settings, and most (160 studies) were based in outpatient practices. Secondary outcomes (health-related quality-of-life, functional status, and suicide) were reported too infrequently for analysis. More than 90% of the randomized trials used double-blinded methods, but fewer than 5% reported whether blinding was successful. Few studies described the method of randomization or allocation and concealment. Approximately 30% of studies had relatively low dropout rates ( 20%), and approximately 20% reported dropout rates exceeding 40%. Analysis of adverse events was complicated by variability in data collection, including voluntary reporting, generic questioning, and standardized scales that may differ and affect the reliability of the overall estimates. 2.2 Major Depression: Newer Antidepressants for Initial Treatment The lifetime risk for major depressive disorder ranges from 10% to 25% for women and 5% to 12% for men, with a point prevalence rate of 5% to 9% for women and 2% to 3% for men (2, 6, 57). It affects persons of all ages, ethnicities, and socioeconomic circumstances. Major depression is characterized by at least 2 weeks of depressed mood or loss of interest or pleasure in nearly all activities (58). The person must experience at least four additional symptoms drawn from a list of vegetative (for example, loss of appetite) and psychological (for example, difficulty concentrating or making decisions) symptoms. In addition, the symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning. In the trials that we reviewed, the average severity of depression was moderate to moderately severe, as measured by a standard symptom rating scale (mean score, 24 [range, 14 to 32], stand

A Randomized Trial of Physical Rehabilitation for Very Frail Nursing Home Residents

Hearing impairment is one of the most common chronic health problems of elderly Americans. Although adverse effects on quality of life are thought to be considerable, they have not been rigorously evaluated. This study was designed to identify the types and extent of dysfunction experienced by elderly individuals with hearing loss, and to define the most appropriate measures for assessing this dysfunction. Elderly male veterans attending a primary care clinic were screened for hearing loss and had their quality of life assessed with a comprehensive battery of disease‐specific and generic measures. Of 472 people who had their hearing tested, 106 had hearing loss. Hearing loss was associated with significant emotional (P = .0001), social (P = .0001), and communication (P = .02) dysfunction. Most individuals (66%) perceived these dysfunctions as severe handicaps even though audiologic loss revealed only mild to moderate impairment (pure tone average loss, 27–55 dB). Adverse effects were best detected with disease‐specific rather than generic functional status measures. We conclude that hearing impairment is associated with important adverse effects on the quality of life of elderly individuals, and that these effects are perceived as severe handicaps even by individuals with only mild to moderate degrees of hearing loss.

Depressive disorders in primary care: prevalence, functional disability, and identification.

BACKGROUND Past studies suggest multidisciplinary interventions that include physical therapy (PT) can improve function of nursing home residents. This trial specifically evaluates effects of PT for frail long-stay nursing home residents. DESIGN Randomized, controlled trial. SETTING One academic nursing home and eight community nursing homes. PATIENTS A total of 194 elderly nursing home residents dependent in at least two activities of daily living residing in the nursing home for at least 3 months. INTERVENTIONS Patients were randomized to individually tailored one-on-one PT sessions or friendly visits (FVs) three times a week for 4 months. Physical therapy included range-of-motion, strength, balance, transfer, and mobility exercises. MAIN OUTCOME MEASURES Performance-based physical function assessed by the Physical Disability Index; self-perceived health status assessed with the Sickness Impact Profile; observer-reported activities of daily living; and falls. RESULTS Eighty-nine percent and 92% of PT and FV sessions, respectively, were attended; 5% and 9% of subjects dropped out in the PT group and FV group, respectively. Compared with the FV group, the PT group experienced no significant improvements in overall Physical Disability Index, Sickness Impact Profile, or activities of daily living scores. A 15.5% improvement in the mobility subscale of the Physical Disability Index was seen (95% confidence interval [CI], 6.4% to 24.7%); no benefits in range-of-motion, strength, or balance subscales were found. Compared with the FV group, the PT group used assistive devices for bed mobility tasks less often (P = .06) and were less likely to use assistive devices and wheelchairs for locomotion (P < .005). There were 79 falls in the PT group vs 60 falls in the FV group (P = .11). Charge for the 4-month PT program was

Psychosocial service use and unmet need among recently diagnosed adolescent and young adult cancer patients

1220 per subject (95% CI,

Correlates of successful hearing aid use in older adults

412 to

Falls: an examination of three reporting methods in nursing homes.

1832). CONCLUSION This standardized physical therapy program provided modest mobility benefits for very frail long-stay nursing home residents with physical disability due to multiple comorbid conditions.

Psychological distress and unsatisfied need for psychosocial support in adolescent and young adult cancer patients during the first year following diagnosis.

OBJECTIVES: To assess the relative prevalence of subsyndromal depression (SubD) and major depression (MDD) in primary care patients and describe their associated functional impairments, and to define the operating characteristics of a short depression screen (SDS).SETTING: Three primary care clinics: a university-affiliated Veterans Affairs clinic, a county general internal medicine clinic, and a community health center.SUBJECTS: Randomly selected adult patients (n=221), aged ≥30 years, with no history of psychiatric comorbidity, current substance abuse, major depressive disorder, chronic pain disorder, or dementia.MEASUREMENTS: The SDS and the Medical Outcomes Study Short Form 36 (SF-36) were interviewer-administered by an experienced bilingual research assistant to all subjects in the language of their choice. A physician administered independently the Structured Clinical Interview for DSM-III diagnosis (SCID) and the Hamilton Depression Rating Scale (HDRS) to all patients who exceeded a minimum threshold on the SDS and to a randomly selected sample of patients who had subthreshold scores. MDD was defined by DSM-III criteria and SubD was defined as two to four DSM-III criteria, of which one had to be depressed mood or anhedonia.RESULTS: Demographic and clinical characteristics of the patients were: Mexican American 53%, non-Hispanic white 38%, and African American 9%; men 68%; mean age 60±12.7 years; mean level of education 9.5±4.4 years; and hypertension 57%, diabetes mellitus 51%, and arthritis 45%. The prevalences of MDD and SubD (adjusted for sampling strategy) were 4% and 16%, respectively. For the patients who had MDD, the median HDRS score was 17 (interquartile range, 10–18), and for those who had SubD, the median HDRS score was 9 (interquartile range, 8–14). Compared with the patients who did not have depressive symptoms, those who had either MDD or SubD were significantly impaired in multiple domains of self-reported function. The sensitivity and specificity of the SDS for MDD were 100% (95% CI 57–100) and 72% (95% CI 63–81), respectively. For depressive disorders (MDD or SubD), the sensitivity was 66% (95% CI 49–83) and the specificity was 79% (95% CI 69–89).CONCLUSIONS: SubD was more prevalent than MDD in these primary care settings. Both MDD and SubD were associated with significant functional impairment. The sensitivity of the SDS was lower for identifying depressive disorders (MDD or SubD) than it was for identifying MD.

Prevalence and predictors of post‐traumatic stress symptoms in adolescent and young adult cancer survivors: a 1‐year follow‐up study

Adolescents and young adults (AYAs) with cancer demonstrate biomedical risks and psychosocial issues distinct from those of children or older adults. In this study, the authors examined and compared the extent to which AYAs treated in pediatric or adult oncology settings reported use of, and unmet need for, psychosocial support services.